Department of Infectious Diseases and Neuroinfections, Medical University of Bialystok, Poland

Anna Moniuszko-Malinowska

Medical University of Bialystok

TICKS

Photo by Dr M. Kondrusik, Bialystok, Poland

7oC

10oC

IXODES TICKS SEASONAL ACTIVITY

Based on: Randolph et al, 1996

WIDE RANGE OF TICKS HOSTS

TBE virus

Flaviviridae (other close relatives: Omsk hemorrhagic fever virus,

Kyasanur forest disease virus, Louping ill virus, Langat virus,

Yellow Fever, West Nile, Japanese Encephalitis, Dengue viruses)

3 subtypes:

1.Western European subtype (formerly Central European

encephalitis virus, CEEV; principal tick vector: Ixodes ricinus)

2.Siberian subtype (formerly West Siberian virus; principal tick

vector: Ixodes persulcatus)

3.Far Eastern subtype (formerly Russian Spring Summer

encephalitis virus, RSSEV; principal tick vector: Ixodes persulcatus)

Mandl et al., 1997; Grard et al., 2007

Drinking unpasteurized milk of goat or cow

TBE virus can be isolated from goat's milk, even after 25 days of

milking

Dairy products: yogurt, cheese, butter may be infectious

Pasteurization completely protects against infection!

Foodborne TBE

Balogh et al., 2010

Based on www.pzh.gov.pl; www.ecdc.europa.eu

Forestry workers

National Parks employees

Mushrooms pickers

Berry pickers

Hunters

Dogs owners

RISK GROUPS

Depending on location of inflammatory process

neurologic phase of infection may take course of:

Meningitis

Meningoencephalitis

Meningoencephalomyelitis

Clinical presentation

Maximova et al., 2009

www.humanillnesses.com

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Headache Fever Vomits, nausea

TBE - COMPLAINTS

Czupryna et al., 2011

TBE – PHYSICAL EXAMINATION

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Menigeal signs Oppenheims'

sign

Ataxia Consciousness

disturbances

Paresis

Czupryna et al., 2011

(% of patients)

TBE – DIAGNOSIS-LABORATORY TESTS

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ESR WBC AIAT

Czupryna et al., 2011

• Cerebrospinal fluid examinations

• Pleocytosis – 5 – 1000 cells/µl

• Lymphocytes predominate

• Protein concentration – normal or elevated

(>50 mg/ml)

• Glucose concentration - normal

TBE – LABORATORY TESTS

TBE – DIAGNOSIS- SEROLOGY - ELISA

Holzmann et al., 2003

a) no possibility of causative treatment

b) antioedematous drugs (mannitol, diuretics)

c) pain-killers

d) antinflammatory drugs (NSAID)

e) steroids (exceptional cases)

TBE – TREATMENT

Neurological sequelae - 144 (23.2%):

spinal nerve paralysis (23.7%)

ataxia (23.7%)

disorders of sensibility (13.2%)

All patients with neurological sequelae

required rehabilitation.

SERIOUS SEQUELAE

Zajkowska et al., 2013 Czupryna et al., 2011

2 years after TBE,

intensive physiotherapy

Right lower limb paresis Atrophy of right lower limb

Photo by Prof. J. Zajkowska, Bialystok, Poland

Right brachial plexus paresis

Photo by Prof. J. Zajkowska, Bialystok, Poland

Bilateral brachial plexus paresis

Photo by Prof. J. Zajkowska, Bialystok, Poland

Tetraparesis; cranial nerves paresis Photo by Prof. J. Zajkowska, Bialystok, Poland

• Horizontal nystagmus

• Eye lids falling, dilated eye pupils not reacting to light (brainstem affected)

• Paresis of cranial nerves: VII dx, XI

• Weakness of shoulders muscules

IN THE COURSE OF TBE

Photo by Prof. J. Zajkowska, Bialystok, Poland

1 year after the TBE meningitis; resolving lesions

1-3 months after the TBE meningitis ; persistent headaches

Photo by Prof. J. Zajkowska, Bialystok, Poland

Daefness

Vision impairment

Vegetative (over 50% of patients): hyperactivity

irritability

mood changes

sweats

Intelectual problems: concentration (64%)

memory disorder (79%)

Psychiatric syndromes: neurasthenia (5.17%)

depression (15.1%)

psychoorganic (17.24%) Pancewicz et al., 2006

TBE – Sequelae

Psychiatric sequelae - 272

patients (43.8%):

cognitive disorders (42.1%) depression (28.9%) sleep disorders (13.2%) anxiety (10.5%)

Czupryna et al., 2011

• Mortality rate: 1-4%

• 68-years old female, coinfection with Listeria

monocytogenes

• 71-years old female for 20 years treated with steroids – RA

• 66- years old kidney transplant recipent

• 64-years old female, two years after renal transplant

• (on immunosupression)

TBE – LETHAL CASES

September 5, 2012 the European Commission published an official decision on the addition of TBE to the list of notifiable diseases in the European Union September 18, 2012 the ECDC published raport about: • Implementation of the standard case definition of TBE infection • Collecting standardized, comparable data at EU level • The need to develop recommendations for immunization of EU

citizens as well as for those traveling to areas endemic of this disease!

• Travel medicine!!!!!

1. Official Journal of the European Union, 5.9.2012, L 239/3, http://eurlex.europe.eu 2. Epidemiological situation of tick-borne encephalitis in the European Union and European Free Trade Association

countries, Technical Report, The European Centre for Disease Prevention and Control (ECDC), http://www.ecdc.europa.eu/en/publications/Publications/TBE-in- -EU-EFTA.pdf

3. World Health Organisation (WHO) Background Document on Vaccines and Vaccination against Tick-borne Encephalitis (TBE), 2011, http://www.who.int/immunization/sage/6_TBE_backgr_18_Mar_net_apr_2011.pdf

Non specific- avoiding tick bites, proper clothes in

nature, use of repelents

Specific- vaccination

TBE – PROPHYLAXIS

persons residing in areas with increased risk of the disease:

foresters

soldiers

firemen

border guards

farmers

trainees in forest areas

tourists, participants of colonies and camps

it is recommended when travelling to countries where the disease is endemic, especially if there is a risk of a tick bite

TBE – Vaccination -

Recommendation

Austria Albania Belarus Bosnia Croatia Czech Republic Denmark Estonia Finland France Greece Hungary Italy Lithuania Latvia Moldova Germany Norway Poland Romania Russia Serbia Slovakia Slovenia Sweden Switzerland Ukraine

Kollaritsch et al., 2010; WHO, 2010

1st Vaccine – 1970 - (Immuno AG Austria)

In Europe

FSME – IMMUN Baxter AG - Pfizer

Encepur - Novartis - GSK

Both vaccines – highly immunogenic

Antibodies, produced after vaccination, have cross-neutralizing response against various strains of the virus of TBE in Europe and Asia (including Siberian and Far Eastern subtype)

TBE – PROPHYLAXIS

Kunz et al., 1976; Heinz et al., 2007; Kunz, 2003

Administrated in 3-steps scheme - 0, 1-3 and 9-12

months; booster every 3- 5 years

If the need for rapid immunization (simlilar response):

1. For Encepur® a rapid immunization schedule is licenced with 3 vaccinations on

days 0-7-21 and a first booster after 12-18 months

2. For FSME-Immun® the rapid immunization (“modified or accelerated conventional

schedule”) consists of vaccinations on day 0 and 14 and an (early) third vaccination

after 5-12 months (for the adult formulation) and a booster after 12-18 months

TBE – Vaccination - Schedule

TBE – VACCINATION - RATE

Reasons: - Vaccination cost

(refunded only for foresters)

- Lack of the awareness of the disease and vaccination